Every patient is an immigrant in the doctor’s office

One of my favorite conferences is The Conference on Practice Improvement hosted by the Society of Teachers of Family Medicine (STFM) and American Academy of Family Physicians (AAFP).

For all the upset and negativity there seems to be toward doctors, these family docs are in it — each and every one that I’ve met — for the good of their patients. And that is why I think every one of them should take heed of the astute comment in his intro to the book, Patients and Doctors: Life-changing stories from Primary Care. Primary care physician Jeffrey Borkan observes: “Every encounter between doctor and patient is a cross-cultural event.”

Doesn’t that put we patients into perspective: whether in the doctor’s office, clinic, lab, hospital, long term care or hospice, we patients are the immigrants. We have to learn their language, protocols, processes and expectations. Then, we each have to figure out our role and how we’re going to negotiate the terrain. Even patients who are activated, engaged, empowered and Type A plus can be taken down by illness like Superman with Kryptonite. The Institute of Medicine (IOM) reports that even we who are educated and skilled find it daunting to wrap our heads around complex health information when made vulnerable by poor health.

Being thrust into sick-land is indeed like being dropped into a foreign culture, with dozens of languages and dialects. Each condition and each disease has its own nuances, acronyms, jargon and short-hand and we have to quickly get up to speed after finding ourselves on these foreign shores. Unlike the health-care professional “natives,” who’ve had years of acculturation and training, we’re expected not only to understand – if not speak – the language, but also to be able to assess, evaluate, analyze and come to an educated conclusion about our care.

It’s a tall order, and even seemingly simple words and concepts can be baffling:

… a middle-age woman, in line for coffee ahead of me, sighed heavily and loudly enough that I asked what was wrong. In accented but perfect English, she explained, “My husband is going for heart surgery. Last year, the doctor told us he was at risk and should take a coated aspirin every day. We didn’t know what he meant, ‘coated’ or why. So we didn’t. And now he’s in surgery.

Whether or not there’s a link between not taking the aspirin and the surgery isn’t the point here. Why were they expected to know the meaning and significance of “coated.” Why didn’t the doctor explain? Why didn’t they ask – if not the doctor, then the pharmacist. Or the doctor’s receptionist, or someone in their own community? Perhaps, as immigrants, they’re not empowered, activated, engaged. Or perhaps because ‘coated’ being such a simple word, they thought somehow they should know what it meant.

They felt stupid for not knowing. The repercussions of that exchange lost in translation go beyond the (possible) physical result. Guilt, anxiety, diminished self-worth, having to answer to other relatives. Why is it up to we who are not feeling well, and who are emotionally embattled and feeling vulnerable, to become acculturated and understand the language of this strange new world?

It’s not just MDs. In a recent committee meeting at the College of Occupational Therapists, an OT said she’d explained to a patient she’d been trained in wound care. As the only civvie at the table, I said – more as a statement than a question, “You’d never say wound care to a client would you.” A brief silence.

“Why not?”

“Because to us patients, ‘wound’ means a gunshot or knife or war wound.”

OTs: well meaning. Dedicated to patient-centered care. Yet they hadn’t considered the impact of the word ‘wound’ on someone without health care (or combat) training.

I sure wish every health care professional would consider Dr. Borkan’s observation. Patients and health care professionals: two different cultures. What will it take to get us speaking the same language?

Kathy Kastner is Founder and President of Ability for Life.

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Every patient is an immigrant in the doctor’s office 13 comments

Legally, “immigrant” versus “non-immigrant” is merely an issue of intent. An immigrant to the US intends to remain in the US, acclimate to the US culture and join the American people. A non-immigrant has zero intention of remaining in the US and is here only for a visit. The non-immigrant plans to leave the US and return to his or her own country and culture.

Extending the immigrant/non-immigrant definition to a medical setting and adding a dash of patient safety: The “immigrant patient” presents as an individual who enters the doctor’s office wanting to become a part of the particular office’s culture and process (ie. the patient wants to feel welcomed and safe).

As with the immigrant in the US, the immigrant patient may already have some “language skills” and experience.

It seems absolutely reasonable for medical professionals to assess the individual patient’s level of cognitive understanding and life experiences. Not every patient needs to be treated like a non-English speaking immigrant. But (nearly) every patient wants to be treated as though they intend to be a part of the particular office’s culture process.

Great analogy. As always, patient-by-patient. (Most of us patients will always ask about “coating” on donuts! When our docs mention “coated pills,” we patients have the responsibility to ask more questions. If not at that appointment, we should contact the office later.)

doc99

I wonder what the Society of Teachers of Family Medicine feels about Family Medicine Residents and Program Directors making phony excuse notes in Wisconsin?

I wonder what Wisconsin State Medical Board makes of the phony notes. The docs say they performed a “medical examination” per the written excuse. It seems the “patient” understands the language though.

Maribel

Can students in WI pull that same “excuse note because of stress” thing like some of their teachers used? I’d imagine there are plenty of kids living in stressful homes that are still expected to show up to class.

I’d agree the burden is on the patient to make sure he understands what the doctor is saying. If you don’t understand something, you need to speak up.

I have nothing but respect for doctors who will put their careers on the line to stand with the people. When the greedheads get around to noticing that your salary is a source of potential profit, it will be thanks to doctors like that that the people stand with you.

I like the immigrant analogy. However, our government recognizes the need for patients to be more involved in medical decision making, thus the new ACA legislation on Shared Decision-Making. MDs need to provide physician aids according to their patients’ age, educational level and language. New electronic patient aids can educate the patient, help the patient make choices and create an environment where the patient and physician truly share in the patient’s treatment decision.

Hi Kathy,
Thank you for this excellent info from such a unique perspective. I’d also add to your invaluable list of immigration issues (language, protocol, processes, expectations) one more important emotional challenge: patients can also be frightened, helpless, confused, terribly ill, and overwhelmed by what’s happening to them.

After my heart attack, my doctor, too, commented one day that surviving a cardiac event experience is a lot like moving to a foreign country.

But unlike planning a fun-filled vacation adventure to a foreign country, this is one of those war-torn, civil strife-ridden, bad-food-and-weather faraway destinations you see on the news but never, ever want to actually visit.

You don’t speak the language. You’re unfamiliar with the culture. As a fellow heart attack survivor described her own cardiac event: “We were brides, taken away without choice, as my grandmother was in 1918. There was no anticipation of emigration, or dreams of the future. We took no oath of happy citizenship ~ it was the trip of survival, like boat people.”

“New electronic patient aids can educate the patient, help the patient make choices and create an environment where the patient and physician truly share in the patient’s treatment decision.’

I’m not discounting all this new “stuff,” but what I see being talked about here is much less tangible. It involves the “unseen” aspects of any culture, the “elephants in the room.” How welcome patients feel in this alien culture begins with the telephone call to the receptionist. How friendly is this encounter? It even involve how difficult it is to find a parking space for the appointment. How comfortable is waiting room? How is the patient greeted? If tests are required before hospital admission or surgery, how respected does the patient feel during those tests? Frankly, the state is set significantly before the patient even sees his hospital team or his doctor. If the patient has felt safe and respected all along the way during these initial steps, he/she is more likely to feel good later on. How does the hospital building or doctor office feel to the patient? Does it feel completely institutional or does it have a more friendly, personal touch? These questions may see ridiculous, but we communicate much more with this kind of “stuff” than we do with words.

Excellent points, Doug. I recall coming “home” to Vancouver after a trip to New York City where the magnificent YVR international arrivals level had two directional signs, one for returning Canadian citizens and one for visitors. As I progressed along the lineup under the Canadian sign, I eventually came to another sign that said: “WELCOME HOME!” It brought tears to my eyes.

Are most doctor’s offices and hospital waiting areas and front desk staff answering the telephone when we call for appointments as welcoming as a big impersonal airport? Hardly!

Nurses as well as other health professionals are mired in their own “talk”. I tried to make some “translation” a part of an inpatient satisfaction improvement program (based on the US “Speak Up” campaign) but was howled down by all the nurses in the focus group [I was the researcher, a psychologist]. While doing my interviews with the patients I casually asked some of them what they thought was meant by terms such as “ventilation” and “cross-matched”- most had little idea, so weren’t sure what was happening to them. When people said they were in for a gall bladder removal, I asked them what the gall bladder did for them normally- no one had the faintest idea, except that it made “gall”! The same with liver, pancreas, bowel, colon- they had little idea what any of these organs contributed to their life and how they might feel if parts were removed or damaged. I felt that they hadn’t really given “informed” consent to their procedures, but I seem to be a lone voice! Overall, I think that health matters are still on a cultural island in a sea of everyday life. This has big implications for convincing people to fight obesity in order to save their health decades into the future.

Interesting point, Murf. I completely agree with the jargon issue – a real barrier in doctor/patient communication. When I was in the E.R. (en route to the O.R. in mid-heart attack), doctors were casually throwing around words like “troponins” and “T-waves” as if I knew what the heck they were talking about. I had to hold my hand up at one point and remind them I’d never been to medical school…. After the fact, I was given a pile of reading material while in CCU, and shown four short videos about what had just happened to me. Very educational.

But at what point would we expect an average patient about to undergo non-emergency gall bladder surgery to make some kind of an effort to find out what the gall bladder actually does? Whose responsibility is it to educate that kind of patient? Should doctors’ offices have simple handouts or patient videos covering common medical procedures? I’ve been very surprised by heart patients who visit my site with basic questions that, really, should only be answered in one way:

In many instances, the concept of “informed consent” has ceased to be an aspect of communication — but rather it has become an aspect of CYA. It’s assumed that if the doctor (1) explains the procedure in any form; (2) hands out all kinds of reading material to the patient; (3) gets the patient to sign something that says this was done — that if all this is done, “informed consent” is covered.
When you dealing with this kind of technical information, trying to communicate it to those not educated in the subject — it’s really a teaching issue. Like teachers, doctors need to “test” for comprehension and understanding. They need to ask the patient to explain back what’s been said. Now, I know this is a question of having enough time to do this. And I know there is never enough time. And I agree that patients need to do their own research and reading. But the material they read must be written in a way that is both accurate and level that is comprehensible. I’m not convinced this is always done. And I’m not saying this is an easy problem to solve.